IHXV

5
Notifications

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- NEW
- 5 min
  
  New Patient Added
- EARLIER
- Patient10 min
  
  Check the detail of the patient
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Patient Registration Form

Personal Information

Title

First Name*

Middle Name

Last Name*

Gender

Date of Birth*

Marital Status

Occupation

Religion

Nationality

Contact Information

Mobile No.*

Alternate Contact

Email ID

Address Line 1

Address Line 2

Country

State

City

PIN Code

Guardian / Emergency Contact

Guardian Title

Guardian Name

Relation with Patient

Guardian Mobile

Guardian Address

Guardian Email

Arrival Details

Date and Time*

Payment Type

Cash

Credit

Medical Information

Department*

Consulting Doctor*

Referred By

Blood Group

Allergies

Existing Illness

Past Surgeries

Allocation

Allocation

Unit No

Profession and insurance Details

ID Proof Type

ID Proof Number

ABHA No.

Health Insurance Provider

Payer Name

Policy Number

Card Number

Remark